- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,011.87 / $12,589.25
| Facility | | $1,548.82 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $812.83 / $1,737.80
| Professional | | $512.86 | $812.83 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $691.83
| Professional | | $512.86 | $512.86 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $7,943.28
| Facility | | $3,090.30 | $4,073.80 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,412.54
| Professional | | $588.84 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,187.76
| Professional | | $1,230.27 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,122.02 / $4,265.80
| Facility | | $512.86 | $1,122.02 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $4,168.69
| Professional | | $1,023.29 | $1,412.54 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,187.76
| Professional | | $1,288.25 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $1,737.80
| Professional | | $1,230.27 | $1,659.59 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,365.16 / $8,128.31
| Facility | | $2,951.21 | $4,365.16 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $1,778.28
| Professional | | $776.25 | $1,202.26 | $1,778.28 |